Care of sick children. Cancer in children Caring for children with cancer

What are the features of the work of a nurse with cancer patients?

A feature of caring for patients with malignant neoplasms is the need for a special psychological approach. The patient should not be allowed to know the true diagnosis. The terms "cancer", "sarcoma" should be avoided and replaced with the words "ulcer", "narrowing", "compaction", etc. In all extracts and certificates issued to patients, the diagnosis should also not be clear to the patient. You should be especially careful when talking not only with patients, but also with their relatives.

Cancer patients have a very labile, vulnerable psyche, which must be kept in mind at all stages of care for these patients.

If consultation with specialists from another medical institution is needed, then a doctor or nurse is sent along with the patient to transport documents. If this is not possible, then the documents are sent by mail to the head physician or given to the patient's relatives in a sealed envelope. The actual nature of the disease can be reported only to the closest relatives of the patient.

What are the features of the placement of patients in the oncology department?

We must try to separate patients with advanced tumors from the rest of the flow of patients. It is desirable that patients with early stages of malignant tumors or precancerous diseases do not meet patients with relapses and metastases. In an oncology hospital, newly arrived patients should not be placed in those wards where there are patients with advanced stages of the disease.

How are cancer patients monitored and cared for?

When monitoring cancer patients, regular weighing is of great importance, since weight loss is one of the signs of disease progression. Regular measurement of body temperature allows you to identify the expected decay of the tumor, the body's response to radiation. Measurements of body weight and temperature should be recorded in the medical history or in the outpatient card.

In case of metastatic lesions of the spine, often occurring in breast or lung cancer, bed rest is prescribed and a wooden shield is placed under the mattress to avoid pathological bone fractures. When caring for patients suffering from inoperable forms of lung cancer, exposure to air, tireless walks, and frequent ventilation of the room are of great importance, since patients with a limited respiratory surface of the lungs need an influx of clean air.

How are sanitary and hygienic measures carried out in the oncology department?

It is necessary to train the patient and relatives in hygienic measures. Sputum, which is often secreted by patients suffering from cancer of the lungs and larynx, is collected in special spittoons with well-ground lids. Spittoons should be washed daily with hot water and disinfected with a 10-12% bleach solution. To destroy the fetid odor, add 15-30 ml of turpentine to the spittoon. Urine and feces for examination are collected in a faience or rubber vessel, which should be washed regularly with hot water and disinfected with bleach.

What is the diet of cancer patients?

Proper diet is important. The patient should receive food rich in vitamins and proteins at least 4-6 times a day, and attention should be paid to the variety and taste of dishes. You should not follow any special diets, you just need to avoid excessively hot or very cold, rough, fried or spicy foods.

What are the features of feeding patients with stomach cancer?

Patients with advanced forms of stomach cancer should be fed with more gentle food (sour cream, cottage cheese, boiled fish, meat broths, steam cutlets, chopped or mashed fruits and vegetables, etc.) spoons 0,5-1 % hydrochloric acid solution.

Severe obstruction of solid food in patients with inoperable forms of cancer of the cardia of the stomach and esophagus requires the appointment of high-calorie and vitamin-rich liquid foods (sour cream, raw eggs, broths, liquid cereals, sweet tea, liquid vegetable puree, etc.). Sometimes the following mixture contributes to the improvement of patency: rectified alcohol 96% - 50 ml, glycerin - 150 ml (one tablespoon before meals). The intake of this mixture can be combined with the appointment of a 0.1% solution of atropine, 4-6 drops per tablespoon of water 15-20 minutes before meals. With the threat of complete obstruction of the esophagus, hospitalization is necessary for palliative surgery. For a patient with a malignant tumor of the esophagus, you should have a drinker and feed him only liquid food. In this case, it is often necessary to use a thin gastric tube passed into the stomach through the nose.

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The material was prepared on the basis of the work carried out as part of the program of psychological rehabilitation of families with children who had cancer, on the basis of the Russkoye Pole sanatorium of the Ministry of Health and Social Development of Russia.

A child's oncological disease is a serious test not only for himself, but for his entire family. A sick child and his family are accompanied by many difficulties, not only during the periods of diagnosis and treatment, but also after its completion, in cases of recovery. Going into remission is a rather difficult period in a child's life, because. he suffers from the changes that the disease has brought into his life, and it takes a lot of time and effort to accept them. The disease, being included in the social situation of development, changes the conditions for the flow of many types of activity, which can lead to the appearance of individual psychological consequences that significantly affect the course of natural crises of growing up and the formation of the personality, even in the long-term period after the end of treatment.

There is no doubt that the ontogeny of a child who has had an oncological disease depends on many factors: the psychological problems of the child himself; psychological problems of his parents; the social environment in which the child is located; course of the rehabilitation process.

The main resource of child development lies in the immediate environment, namely, in the family. From parents, first of all, the child should receive support, an idea of himself, a set of strategies for adaptive behavior. But psycho-rehabilitation measures, as a rule, are aimed exclusively at children who have had a disease, which, given the above, is insufficient.

In this regard, one of the important areas is the psychological rehabilitation of families of cancer patients. The goal of psychological rehabilitation at the stage of remission- to help the child and his parents adapt to new living conditions, social space, from which they wean during treatment, due to the length of stay in the hospital and the restrictive regimen after it. It is also important to help them cope with the consequences of the manifestation of psychological trauma received during the treatment phase.

The question arises: why do some families have the opportunity to adapt to the changed living conditions, accept them and contribute to the normal socialization of children, while others, despite a favorable medical prognosis, remain for years in a situation of illness, being isolated from society and in constant anxiety? Obviously, in some families there is a resource for adaptation and movement forward, while in others, the resulting trauma breaks the mechanisms of adaptation.

The construction of rehabilitation work should be based on the need to combine the medical treatment strategy with the implementation of the strategy of psychological and social rehabilitation of the child and his family at all stages of specialized care.

To understand what methods of psychological work can be and what they should be aimed at, it is necessary to highlight the range of problems that such families face. Psychological problems in families of children with cancer are universal in many respects. But the presence in each family of its own history, ways of communication, formed patterns of behavior, undoubtedly, makes us talk about an individual approach to working with each family.

Nevertheless, when working within the framework of the program of psychological rehabilitation on the basis of the Russkoe Pole sanatorium, groups of problems were identified that families who had a child with cancer faced with.

1. Informing children about the nature of their disease

This issue is relevant both at the stage of treatment and during remission. The illness of the child causes strong feelings of parents. The desire to protect children from such experiences forces moms and dads to hide information about the disease. In addition, the presence in society of mythology around the disease creates an idea of it as being subject to concealment. The presence of such a secret increases the emotional distance between parents and the child, contributes to the growth of tension in the relationship. Often their own fear does not allow parents to be frank, although children are quite capable of adequately responding to such information. Also, knowledge about the features of the disease, precautions is necessary for growing children. This allows them to take care of themselves more independently, to be responsible for their health, which helps them to separate in adolescence.

2. Compliance with the restrictive regime for the child

After a difficult long course of treatment and going into remission, parents are worried about the recurrence of oncological symptoms in the child and relapse. The imposed restrictions are especially severe in the first 5 years of remission. In connection with reduced immunity, it is recommended to avoid infections, and, consequently, wide communication with peers, injuries, overwork, overheating in the sun; a special approach to diet is needed. The transferred trials instill persistent anxiety in parents, forcing them to play it safe and not remove the restrictions even after a long period of remission. But the natural process of development of the child's body requires diversity and causes resistance to restrictions, creating tension in the relationship between the child and parents. In addition, this makes it difficult to restore the child's socialization, return him to school, to the children's team, even limits the activities allowed by doctors.

3. Lag in mental development

During consultations, there was often a complaint about a decrease in attention, memory problems in children, especially in those who had just returned to school after home schooling. It has also been observed that after prolonged home schooling, children temporarily lose the ability to concentrate in the classroom. Thus, problems with attention and memory intersect with problems of adaptation to school.
As a rule, this is associated with the period of treatment, when the issue of saving life and health is relevant. The child's body is under the strong influence of various drugs that disrupt the natural and consistent course of development of the whole organism. Chemotherapy, radiation, of course, affect numerous structures. There is a slowdown in both the physical and mental development of the child. But as the child's body recovers and adapts, developmental compensation is achieved, which can vary in time for each child individually.

4. The appearance of fears

Many children experience fear after treatment. This is due both to the effect of drugs on the nervous system, and to the transferred psychotrauma. There is a fear of closed spaces, a pathological fear of infections, darkness, etc.

5. Manifestation of aggressive tendencies in children

Specific complex treatment for oncological diseases affects the psyche of children. Impulsivity, emotional lability, expression of aggression worries parents, makes them turn to a psychologist about this.

Moreover, these aggressive manifestations, based on the results of the drawing tests "Non-existent animal", have a protective tendency. In the drawings of different children, on the depicted non-existent animals, signs of increased aggressiveness abound - various protrusions and outgrowths. But in the context of the children's description of the drawing and the purpose of these: spikes, claws, fangs, etc., the need to defend themselves from enemies appears. The same reason includes the presence in the drawings of signs of verbal aggression - the toothiness of a non-existent animal. In the drawings of children in remission, one can note the presence of details and signs related to the manifestation of protective tendencies and verbal aggression (claws, spikes, needles, teeth).

Fig 1. Drawing "Non-existent animal" by Anna, 8 years old.

Description of the drawing by Anna: the name of the animal is Crocodile-eater. Lives in Africa, makes nests in bogs. Eats crocodiles, other living creatures, including people, drinks blood. There are friends: lions, pythons, boas, piranhas, they hunt together. In his spare time, he rests and explores the area. The body is protected by a hard skin and hard spikes. Enemies: panthers, elephants, vultures, bison. He is afraid of a man because he is dangerous, with a gun. Desires: - to settle all over the world; - so that natural disasters are rare (fires, earthquakes, tornadoes).

For many children after cancer, the external environment seems threatening. Such a reaction is possible against the background of painful treatment, a secluded lifestyle, an unfriendly attitude of peers and difficulties in establishing contact with them. Fearing this frightening environment, the child seeks to defend himself through aggressive actions.

6. Difficulties in the parent-child relationship

This topic in itself often requires special attention in the upbringing of children. But a child's oncological disease introduces certain specifics into these relationships. A sick child at the time of treatment is given maximum attention and care. This is a necessary condition for recovery. After a difficult long course of treatment and going into remission, parents are worried about the recurrence of oncological symptoms in the child and relapse.

Gradually, this need loses its relevance, but for the parents of a recovering child it is often difficult to return to the educational framework that was before the disease. The consequences of the action of chemotherapy on the nervous system are expressed, in particular, in the increased irritability of the child, his tantrums. Keeping a clear predictable position with the imposition of restrictions and the presentation of the necessary requirements seems tough and difficult for parents to implement, they tend to condone whims, adapt to them rather than act consistently (especially if they feel guilty of illness). As a result, during remission, against the background of a gradual functional recovery of the nervous system, the child's problematic behavior is consolidated, the child "learns" to manipulate his parents with the help of tantrums and disobedience. Increased attention at the stage of recovery turns into overprotective parental functions, which also entails difficulties in parent-child relationships. The transferred trials instill persistent anxiety in parents, forcing them to play it safe and not remove the restrictions even after a long period of remission. With such a line of parental behavior, it is especially difficult for adolescents who are deprived of the opportunity to learn independence and responsibility for themselves. In the struggle for independence, teenagers are in sharp conflict with their parents. .

7. Relationship Difficulties with Siblings

If there is a sibling in the family, there is a disproportion in the relationship of adults to an initially healthy and recovering child. This causes misunderstanding and jealousy of one of them, which ultimately leads to tension both in the relationship between siblings and in parent-child relationships. A healthy sibling often perceives the long stay of one of the parents (usually the mother) in the hospital as a neglect of him and holds a grudge for a long time, especially if, after the parent returns home, the long-awaited participation does not turn out to be the desired amount. A sick child, on the other hand, counts on maintaining the increased attention of the mother and may react painfully to its weakening. This situation provokes the emergence of sibling conflicts.

8. Changes in life values and life in general after the illness of the child from the parents

The specificity of the disease and treatment, the myths that have developed in society about oncological diseases, provoke a feeling of fear in parents for the life of the child, do not give full confidence in the successful outcome of treatment.

The degree of traumatization when confronted with these feelings depends on the length of time spent in a stressful situation. The personal characteristics of the parents, the severity of the course of the disease and treatment, the medical prognosis, the presence of psycho-traumatic episodes in personal history, etc. also affect. children. The completed work of grief at loss contributes to the discharge of saturated negative emotional reactions.

With successful treatment, movement towards recovery, the critical uncertainty of the state of the disease is overcome. Parents who have undergone strong feelings, when the child's condition improves, interrupt the process of mourning. At the same time, the saturation of emotional experiences during the treatment period is preserved and updated at the slightest reconstruction of the threat to the child. This causes a change in life priorities depending on the strength of the traumatization. As a rule, the topics of life and health of significant loved ones come to the fore, against the background of leveling everything else. In turn, this determines the direction of development of the sphere of life and functioning in society. So, for example, many mothers after a child's illness refuse to continue their professional career, becoming housewives, deciding to devote themselves to maintaining the health of their loved ones and monitoring them. Often there is a refusal of pleasure, bordering on self-punishment, the loss of a circle of friends. There is a loss of resources to restore physical and moral strength, and emotional stress is growing. In addition, the focus solely on the needs of the child, although it fills the life of a woman with meaning, makes the son or daughter dependent on her, hinders their full return to society, hinders their development.

9. Change in marital relationship

Oncological disease of a child requires quick and timely decisions of parents for its treatment. The family is under the influence of a powerful stressor that affects each member differently. After the primary stress from the diagnosis, the family needs to redistribute functional responsibilities to solve new problems associated with the treatment of the child. At this stage, the already established relations between spouses and the degree of flexibility of the family system are of great importance. Depending on this, the spouses either show mutual support and adjust to the new conditions of functioning (20.8% of families undergoing treatment at the Russian Field sanatorium), or distance themselves and show destructive forms of relationships (17.7% of families). In any case, marital relations are transformed.

An important factor in reducing parental trauma is their ability to provide emotional support to each other. Of great importance is the nature of the relationship between them before the child's illness. It has been observed that families in which distancing was adopted as a response to stress are more difficult to adapt to a situation of a serious illness of a child. At the same time, the spouses find themselves in isolation from each other and try to cope with grief alone, which exacerbates the experience. A frequent option may be the departure of one of the spouses (usually the husband) into dysfunction (alcoholism, job loss, etc.). The grievances arising from this, unspoken mutual claims, the severity of experiences cause a deterioration in relations and can lead to their break, often during the hospitalization of the child (7.7% of families). Then the trauma of divorce is superimposed on the trauma associated with the disease.
It was also noted that even in couples who successfully restructured their interaction during an illness, maintaining trust and emotional closeness, there is a refusal to spend joint leisure time. As you know, joint marital leisure is a significant resource for maintaining and developing the marital subsystem. Refusal of it reinforces the child's triangulation, deprives him of possible autonomy, and deprives his parents of a full-fledged marriage.

10. Issues related to the birth of subsequent children

The fear of losing a child can actualize the issue of the birth of younger siblings. As a problem, endowing the future newborn with the image of a potentially replacing child arises. Also, the potential for them to donate cells can act as a motivation for the birth of a second child. Such an attitude towards reproduction is a consequence of the impact on parents of strong stressors and shows the degree of injury. In addition, against this background, the occurrence of psychogenic infertility is possible, when in case of physical reproductive health there is an inability to conceive. This is probably caused by a conflict of attitudes: a potential child is needed as a substitute or a donor, but there is a fear that he may also get sick. Or: a newborn will require the attention of parents, respectively, a child who has been ill will receive less of it, which may be fraught with a relapse unnoticed in time.

11. "Stuck" in a situation of illness in connection with obtaining a secondary benefit

Naturally, this problem was not voiced by clients in the process of counseling and, perhaps, was not always realized. But the strong embedding of the disease in the family system does not allow family members to easily refuse to function in the "near-hospital" mode. Spouses who have lost contact directly with each other can communicate about the illness of the child. In this case, the child is "held" in the position of the patient, because such a position preserves his marriage. A socially unadapted mother, fearing her failure in society, can also "get stuck" in a situation of a child's illness, unjustifiably delay his return to school, because this is the only way she feels in demand and competent. In addition, the difficult material conditions of many families make them hope that their children will continue to be disabled, counting on the continued provision of benefits. These moments, explainable from a human point of view, nevertheless, keep children in the position of "sick" even many years after the disease and do not allow them to effectively adapt in life.
Thus, the need for psychological assistance to the families of children with cancer during the remission period is obvious. It draws attention to the extent to which children's problems depend on the emotional state of the parents, on their position. For example, issues of adaptation to society after illness, self-esteem of children are directly related to the influence of parents on these aspects.

The use of different psychotherapeutic directions, approaches and techniques in the work allows a flexible approach to solving certain requests, accordingly responding to the individual characteristics of each family and its members.

Work within the framework of the rehabilitation program based on the sanatorium "Russian Field" showed the feasibility and effectiveness of a combination of family, individual counseling and group meetings of mutual support.

During the work, the techniques of the following approaches were used:

Systemic family approach: circular interview; work with the parameters of the family system, direct and paradoxical prescriptions.
Humanistic approach: empathic listening; containerization; reflection of feelings, etc.
Art therapy: drawing projective techniques - "Non-existent animal", "Happy non-existent animal", "Evil non-existent animal"; drawing tests: "Man - House - Tree"; "A family"; "Family of Animals"
Cognitive-imaginative approach: desensitization - to control the imagination.

When working with children in family counseling mode, as well as when working with them individually, a situation often arose in which the child was embarrassed by the presence of a parent or psychologist, behaved constrainedly, closed to communication. In these cases, the use of drawing tests proved to be useful. This method helps to understand the emotional mood of the child, his idea of himself and others, to identify strategies for his behavior. In addition, this allows not only to interest the child and involve him in a conversation, but also to assess the level of mental development. As you know, the nervous system often suffers during chemotherapy and radiation treatment. With the help of this method, it can be assumed to what extent there are violations of concentration, motor skills, whether there are neurological disorders. Studies of children's drawings have shown that in the development of drawing there are clear age stages that replace each other. With a violation in mental development, there is a delay in the transition of the child from stage to stage, a kind of stop in the early stages, which makes it possible to draw evaluative conclusions. Therapeutic value is to give the child the opportunity to express on paper their unspoken experiences. Also, the high projectivity of this approach makes it possible to obtain material for interpretation in a playful, unobtrusive form. Drawing techniques allow you to see the actual experiences of children, in one form or another, transmitted in the drawings.

The drawing test "Non-existent animal", carried out with a 7-year-old boy Alexei, confirmed the assumptions of preliminary communication about the presence of emotional experiences about his inferiority.

Fig 2. Drawing "Non-existent animal", Alexey, 7 years old.

In the description of the picture "Motya Kotya", the child talks about his "Non-existent animal" as: "About a boy and a girl of 6 and 7 years old, living on another planet in a hollow, crawling on the ground. When they grow up, they will walk. There are friends, also twins. They like to play ball, they like to draw. Their parents live far away. There is a village called "grandmother's" where they often visit."

When diagnosed with neuroblastoma of the retroperitoneal space, at the age of 7 months, Alexei developed paralysis of the lower extremities. After passing a successful course of cancer treatment, gradually adapting to natural conditions, the boy feels different from other children, which causes him emotional distress, difficulties in communicating with peers. For several years he tries to be "just like everyone else", copes with many difficulties, learns to walk. In Alexei's drawing, the animal has a characteristic introverted appearance: closed lines, lack of arms and legs. The absence of limbs can speak not only of the boy's introversion, but also of his actual experiences - the impossibility of moving on his own legs, perceived as absent. However, in the story about the drawing, he suggests such a possibility for "his animal" at an older age. This may indicate his positive vision of his future.

When working with fears, which are often found in children who have undergone a traumatic event (in this case, a serious illness and complex treatment), the use of drawings is an effective tool in psychological work. Offering to paint your fear and "deal with" it in a safe environment not only helps the child, it also gives the parent a tool to help their son or daughter that they can use on their own. Also, informing an adult about the role and function of drawings in the emotional life of children reduces parental anxiety about too gloomy and aggressive images, helps them see the child not as "deviating from the norm", but as expressing his own, not always conscious experiences, from which he, way, helps to get rid of.

In a number of cases, the use of the desensitization technique according to the method of R.P. Lovell, used in the cognitive-imaginative approach, proved to be effective. The presence of unlived grief, pathology of grief, difficult verbalization of experiences, high emotional and physical stress of the client are indications for using this method.

A woman came to one of the receptions, outwardly emotionally detached. From the threshold, she said that she could not be at the reception due to poor health. But, nevertheless, she sat down and started talking. It turned out that her 10-year-old daughter was diagnosed with leukemia in 2004. She did not want to remember the period associated with the diagnosis and treatment because of strong negative emotional experiences. The woman looked depressed and did not make contact, the anamnesis was poor, there was not enough information for hypotheses of the further course of the meeting. In search of resource opportunities, the psychologist offered her a session of relaxing desensitization, to which she agreed. After the first session on controlled imagination, when discussing the emotional reactions experienced during it, the feelings associated with the loss of significant people were actualized: a father and a brother who died shortly before the daughter's illness. During the course of treatment of the daughter's cancer, her husband died. This information helped to focus the work on the experiences of complicated mourning over multiple losses. In total, two relaxing sessions of desensitization for controlled imagination were held. Desensitization sessions allowed the woman to feel muscle relaxation, manage resource images and pleasant memories of the past. This, in turn, made it possible to respond to pent-up emotional experiences and to verbalize unexperienced feelings "stored" for many years.

At the first meeting with the visiting family, different hypotheses about possible directions of work arise. But the first task in any variant of work is to create a favorable, safe environment for interaction. For this, it is necessary to use the techniques of a humanistic approach, which in many ways allow creating a trusting, supportive dialogue. Empathic listening, reflection of feelings, containment create a feeling of support and acceptance. This reduces tension in anxiety states and allows participants in psychological work to more effectively work out topical issues. The humanistic approach makes it possible to replace the diagnosis with the clarification of the value of goals and their choice by the patient himself. The role of the psychotherapist is aimed at creating conditions for the client's personality to achieve its goals, not those goals that the theory predicts or the therapist would like to achieve, but freely chosen by the client himself.

The principles of the humanistic approach have shown their effectiveness not only in individual meetings, but also in the conduct of mutual support groups. Their main idea was to provide the participants with the opportunity to determine the topic of the conversation themselves. With this approach, the group itself determines those relevant topics that are formed during the meeting. The psychologist, on the other hand, monitors compliance with the accepted rules of the group, accompanies and corrects the discussion process, focusing on resource areas (positive, functional experience of coping with the situation). The non-directive position of the leader enables the group members not only to show mutual interest in the study of relevant topics, thereby creating group cohesion, but also to develop and accept their own reflection.
At the group meetings held, the topics of the need and expediency of informing the child about cancer, the degree of restrictive regimen for the child in everyday life, the relationship between the child's disease and the changed parent-child and marital relations were most often discussed. As a rule, parents keep in themselves those experiences that they experienced during the periods of staging and treatment of the disease, worrying about the health and life of their child. When there is a safe environment among like-minded people at group meetings, parents have the opportunity not only to verbalize their feelings, but also to understand that they are not alone in their experiences. In addition, the experience of parents who, having found themselves in a similar situation, were able to cope with their fears and return the child to a full life, provides support and practical advice to those who are still afraid to give up restrictions.
It is worth noting the benefits of informing clients during consultations. A psychologist can provide information about the specifics of the course of the recovery processes of the psyche during remission, about the characteristic signs of age periods in children, about the crises of growing up, about the functional structure of the family, about ways of effective communication, etc. Informing, by providing missing knowledge on a wide range of issues, can reduce anxiety and expand the range of possible actions for both children and parents.

The choice of certain techniques of different approaches was based on the relevance and relevance in each individual case. In family counseling, the techniques of a systematic family approach were used more often than others. They contribute to building a dialogue between parents and children, opening up new sides and opportunities for communication, both for parents and children. When working with a family, when a parent and a child are present at the reception, the circular interview technique contributed to a productive way of interaction. It allows you to obtain data about the family, to focus on discovering differences between the reactions and views of family members, to introduce new information about itself into the family system, to realize the consequences of their behavior for family members. This technique also helps the psychologist to remain neutral towards different family members. Circular questions allow parents to hear from the child about the feelings and ideas that he has in response to certain events in the family or relationships with adults. This makes parents take a fresh look at their child, who, "as it turns out", sees, hears and understands a lot. The circular interview technique promotes rapprochement in relationships, allows you to gain new communication experience and makes it possible to avoid double messages that often frustrate children. This allows the child to feel heard, to be a full participant in the dialogue with the parent, which is important for children striving for "adulthood" and independence.

Difficulties in adapting to school activities, behavioral disorders in children, fears, sibling and parent-child conflicts, etc. - problems for the solution of which the technique of direct and paradoxical prescriptions used in systemic family therapy has proven itself well in counseling. This technique allows you to give impetus to changes in intra-family communication, move away from stereotypical interaction, and gain new experience in communication. For example, when complaining about the child's repeated tantrums, accompanying the performance of lessons and addressed to the mother, a paradoxical prescription was given. The child was obliged to quarrel for five minutes before each homework, while the mother had to make sure that the tantrums were regular, timely and of high quality. After two "mandatory" tantrums, the child refused them: his need for attention and sharing of feelings was satisfied. After that, at a consultation, together with the mother and the child, a detailed plan was developed for a "good" appeal to the mother for help, to which she could not help but react.

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The specificity of caring for sick children of different ages lies in the features of direct observation of a sick child, communication with him, methods of collecting material for laboratory research, and conducting medical procedures.

The creation of a hygienic environment for a sick child consists of general hygienic guidelines for the premises of children's hospitals, hygiene features of a newborn and an infant.

For young children, small chambers or boxes, closed and open, are needed. If an infectious disease is suspected, the child should be placed in an isolation room with special equipment. For mothers hospitalized with their children, a bedroom and a dining room should be allocated. For walks of sick children, a veranda or special rooms with constantly open windows are allocated.

Beds for infants should have high sloping or folding sides. A hard mattress made of horsehair, bast, sea grass is placed in the crib. Do not use mattresses made of fluff or feathers. A small flat pillow is placed under the head.

The air temperature in the ward for a premature baby is 22-26 C, depending on body weight, for a full-term baby - 20 C. Daily systematic ventilation of the wards is necessary at any time of the year.

Clothing should not hamper the movements of the child, but should be light and warm. For swaddling premature babies, it is convenient to use envelopes. Free swaddling is indicated for children with normal thermoregulatory function, regardless of their body weight, age and location (open incubator, bed).

The basis for caring for newborns (full-term and premature) is the observance of the strictest cleanliness, in some cases - sterility. Persons with acute and chronic infectious diseases are not allowed to care for newborns. Wearing woolen clothes and rings is unacceptable.

The staff is obliged to observe the rules of personal hygiene and, at the same time, strictly work in a gauze mask, which is changed every 3 hours. Every month, all employees of the department must conduct a study of mucus from the nose and throat for carriage of diphtheria bacilli, hemolytic streptococcus. Checking the absence of staphylococci in the washout of the hands is also done once a month.

Care of the umbilical wound requires special attention, which should be carried out under strictly aseptic conditions. Every day a newborn is toileted: the eyes are washed with a sterile cotton swab dipped in a solution of potassium permanganate (1: 10,000) or a solution of furacillin (1: 5,000), in the direction from the outer edge to the inner; the nose is cleaned with cotton wicks dipped in boiled vegetable oil (Fig. 122); the child is washed, the skin folds are lubricated; washed away after each act of defecation.

A daily examination of the pharynx of a sick child is necessary. Every day, temperature, body weight, quantity and quality of bowel movements, the presence of regurgitation, vomiting, coughing, asphyxia, and convulsions are recorded. Children are weighed in the morning, before the first feeding.

When assigning a walk, take into account body weight, the age of the child, the time of year and local climatic conditions. Premature babies can be taken out for a walk over the age of 3-4 weeks in the spring-summer period when they reach a weight of 2100-2500 g, in autumn-winter - when they reach a weight of 2500-3000 g. The first walk of these children in winter should not exceed 5- 10 min, in summer - 20-30 min. Full-term babies from 2-3 weeks of age are allowed to walk in winter at an air temperature of -10 C in the absence of wind. If the child has increased cyanosis, cough, pallor, anxiety, the walk stops.

The organization of feeding a sick child requires special clarity, consistency and skill from the staff. Difficulties in feeding may be due to underdevelopment of the sucking reflex, the presence of congenital deformities, the child's refusal to eat, unconsciousness, etc. In such cases, feeding is carried out through a gastric tube, through a pipette, from a spoon; used parenteral and rectal nutrition.

Collecting material from children for laboratory research is difficult and requires special skills. Children under 5-6 years old do not cough up sputum. Therefore, at the moment when the child coughs, with a spatula, holding the root of the tongue, sputum is removed with a sterile swab, which is then inserted into a sterile test tube. In infants, sputum is removed from the stomach using a probe inserted into the stomach on an empty stomach.

Blood sampling for serological, biochemical and other studies is carried out by venipuncture. Excrements for bacteriological examination are collected with a glass tube, melted at both ends, which is sterilized and inserted into the anus. The tube filled with feces is closed at both ends with sterile cotton wool, lowered into a test tube and sent to the laboratory. Feces for research on worm eggs are collected in cleanly washed small glassware. With a cleanly planed stick, feces are taken from 5-6 different places, then the dishes are tightly covered with clean paper.

Caring for a sick child has a number of features. Pediatric staff should receive special training. Parting with relatives, staying in the hospital, medical procedures inevitably injure the child's psyche. The task of the medical staff is to provide care that will maximally weaken the negative impact of the hospital environment. When a child is admitted to a hospital, it is necessary to gently distract him from parting with his relatives; learn about the habits of the child, the regime that was observed at home; there should be toys in the emergency room (it is acceptable to take clean and safe washable toys).

It should be comfortable in the wards, in the arsenal of therapeutic agents there should be toys, pictures, funny books. Frequent ventilation is necessary in combination with air disinfection by ultraviolet irradiation with bactericidal lamps (children staying in the ward wear special glasses). Beds should be with devices that allow you to adjust the height of the headboard, and for young children - with slatted side walls, one of which is folding. Mattresses are better hair or from sea grass, cotton wool. For small children, the mattress is covered with oilcloth, then with a sheet.

Children's departments should have verandas for outdoor daytime sleep; recovering children are allowed to walk.

Of great importance is the mode of the day, corresponding to the age and condition of the sick child.

In the evening, it is necessary to exclude all the moments that excite the nervous system of the child. The diet depends on the age of the child and the nature of the disease: feed should be at the same time, in small portions, slowly; give more liquid (if there are no contraindications), vitamins; cannot be force fed. Children should receive general hygienic or therapeutic baths (see Baths, for children). In seriously ill patients in the morning and at night, wipe the face, neck, skin folds with a cotton swab dipped in warm boiled water. Infants are washed several times a day, after which the child's body is thoroughly dried with a soft diaper, skin folds are smeared with boiled vegetable or vaseline oil. Linen and clothing should be of soft fabric in pleasant colors and carefully selected according to size and age. Educational work is important. For children of school age, with the permission of the attending physician, classes are organized according to the school curriculum.

The nurse maintains a special nursing list for each child, in which appetite, stool and other information are noted.

Tablets for young children should be crushed and mixed with sugar syrup. If the child does not open, you can lightly squeeze his nose with two fingers, while the child opens his mouth to inhale, and the medicine is poured into him. A seriously ill weakened child should be picked up more often so that congestion in the lungs does not occur. In case of vomiting, the child should be quickly planted or laid on its side; at the end of vomiting - rinse his mouth and give him a few sips of cold water to drink. Measurement of body temperature in young children has its own specifics (see Body thermometry).